What My Wife Went Through to Have These Babies

As we watched the movements of the small, glowing forms on the black screen, we waited for the news about our twins. After showing us evidence of male organs on Baby A, the technician pointed to a dim line that proved the femininity of Baby B. We had a boy and a girl. “Yes!” I blurted, flinging my arms in the air. I’d been hoping for one of each—a fitting end to our ordeal of trying to have even one child. Lying on the exam table, my wife, Elizabeth, smiled tolerantly, but I knew she was excited too.

In the strange, constantly changing world of assisted reproduction, the most thrilling moments often occur in a dark room, where hopeful parents cannot be quite sure what they are seeing without instruction from an expert. The simple truth is that we’d arrived at this moment thanks to my wife’s diligence. She’d found one of the best fertility doctors in the country, and a superb obstetric practice that specializes in high-risk pregnancies. She also responded well to treatment and suffered few side effects. Our healthy twins were born after 37 and a half weeks; Edward weighed seven pounds, Eleanor six pounds, four ounces. We’re deliriously happy to have them.

And yet our firsthand experience left me with grave concerns. I could not look away from what we saw happening in the profoundly flawed billion-dollar baby-making industry, now practiced in 400-plus clinics across America. Since 1996 the number of assisted reproduction cycles has more than doubled. (And you’d be surprised by the patients’ ages: 40 percent are younger than 35.)

Despite repeated calls for more regulation in the almost 27 years since the first test-tube baby was born in the United States, the industry continues unchecked in alarming ways. Things have gotten so out of hand that now a small but growing group of doctors and fertility specialists are calling for an end to harmful trends that persist despite advances in technology, including the “epidemic” of multiple births and the lack of adequate counseling—practices that put the health of women and babies at risk.

For us the process of getting pregnant took about a year, including three in vitro fertilization (IVF) cycles. Each cycle involved two and a half weeks of injecting my wife with hormone shots to regulate her egg production; two painful procedures to extract the eggs; days of waiting to see if the eggs, once mixed with my sperm in a petri dish, had merged into viable embryos; another procedure to insert the embryos into her womb; then 10 days of waiting for a pregnancy test. Every attempt was exhausting and anguishing, a strange state of hope alternating with dread. And yet, I later discovered, we were among the luckiest of patients.

Uncertain beginnings

We tried for a year to conceive the old-fashioned way, but in the wake of Elizabeth’s thirty-fifth birthday, we were acutely aware that our chances of pregnancy were quickly declining. She called every friend and doctor she knew until her research led us to a top fertility clinic in New York City. Medical tests had shown that there was nothing “wrong” with us, but given Elizabeth’s age, our doctor recommended intrauterine insemination—the high-tech equivalent of the turkey baster method.

“When do we start?” Elizabeth asked as we sat in the doctor’s office. “My gynecologist told me that I don’t have time to spare.” Her voice was urgent.

“Your tests show you’re ovulating. Why not try right now?” he replied briskly.

Now? I thought we were just finding out what our options were. And I was leaving on a book tour later that afternoon. I certainly didn’t have time to go into a little room with a copy of Penthouse Forum, I thought.

That evening when I called home from my hotel in Portland, Oregon, Elizabeth asked whether I understood how much pain my distracted reluctance had caused her. I spluttered a few defensive replies, but I could hear her anger from across the continent and knew she was right. If we wanted a baby, she reminded me—and I certainly did—then we had to seize our opportunities whenever they arrived.

We didn’t miss another fertile window. We tried intrauterine insemination, and after it failed several times, turned to IVF. Among other things, that meant learning how to inject my wife with powerful drugs. She really, really hates getting shots—and didn’t enjoy my wielding the needle.

Sometimes I fumbled with the needle as she winced in pain. A trace of blood oozed from the injection site a few times, alarming us both. Soon I trained myself to administer the shots expertly, earning back a few points I’d lost for being dim and clumsy. Every day for weeks I injected Elizabeth with potent, hormone-based medications that can cause nausea, vomiting, joint pain, memory problems and even a rare condition called ovarian hyper-stimulation syndrome. Although we saw few side effects, I worried about how these drugs might affect Elizabeth’s health; she, however, remained brave and stoic.

Unfortunately none of the four embryos transferred from our first IVF cycle took hold. And the second attempt produced eggs of insufficient quality, our doctor said. Our chances were only getting worse as the months passed.

The staggering cost of infertility

Statistically, only 28 percent of assisted reproduction cycles result in live births. In other words, many would-be parents repeat the cycle of anticipation, hope and failure time and time again. Like them, we were determined to start our family. After our second cycle failed, our doctor suggested we might have to consider an egg donor or even a surrogate. Later, when I told Elizabeth that I would be open to these options, or even adoption, she burst into tears. Somehow I had failed to understand how shattering it can be for a woman to discover she is unable to conceive and bear her own child. Occasionally she had asked me whether I would agree to adopt if she never got pregnant, and though I always told her yes, her tears that day showed that she wasn’t ready to consider adoption until our other options had been exhausted.

When IVF is your best or even your only chance to get pregnant, it is hard to be realistic about the costs. A child is a blessing without price, to be sure, and yet the final printout on my desk records the exact price of our babies, appointment by appointment, injection by injection, procedure by procedure. Our medical insurance provided coverage for not one but two IVF cycles; we’re among the fortunate few in that regard. Only 14 states mandate at least partial coverage for infertility diagnosis and treatment, including IVF, which can quickly exceed $50,000 if you have to pay for several cycles out-of-pocket. “For the average couple, writing a check that big is a considerable burden,” says Sam Thatcher, M.D., Ph.D., a reproductive endocrinologist at the Center for Applied Reproductive Science in Johnson City, Tennessee. How many times would we try? We knew one couple who went through as many as 10 cycles of IVF over several years without success. The husband did not say how much they had spent, but I guessed that the figure was well over $100,000. They ended up adopting two children and were a beautiful, happy family, and I could tell his unspoken advice was to not sink our very last hopes, dreams and life savings into IVF.

Pregnant, with risks

Elizabeth and I still weren’t ready to give up on IVF, so we started round three. Three embryos were viable this time, and our doctor told us that our chances of success would be greatly enhanced by inserting them all. Fearful of having twins or even triplets, I had misgivings, but we felt obliged to listen. We found ourselves butting up against the darkest reality of IVF: the push to transfer so many embryos that, of course, it can lead to multiple pregnancies.

Doctors have no reliable method of determining which embryos will develop fully, so they often transfer three—and sometimes far more—to ensure that one will survive. Nearly one third of successful assisted-reproduction attempts produce more than one fetus, which has caused a sharp rise in twins, triplets and quadruplets in the past two decades. “We’re having an epidemic of multiple gestations,” says David Keefe, M.D., an IVF specialist and chair of obstetrics and gynecology at University of South Florida College of Medicine in Tampa.

Multiple pregnancies often require a cesarean section, more dangerous than natural birth. Twins suffer more problems than single babies, triplets have more problems than twins, and so on. Multiples are more vulnerable to increased risks, including low birth weight and early mortality. More than half of all twins and 90 percent of triplets are born prematurely.

While it is possible to selectively reduce embryos by using an abortion procedure, doing so can be emotionally traumatic, physically perilous and morally repugnant for some parents. One obstetrician told me that he knew of a fertility specialist who had transferred as many as a dozen eggs with the plan to terminate all but one. While the procedure aims to protect the remaining fetus, in rare cases it can lead to complete miscarriage.

To deal with these issues, other countries have begun regulating how many embryos can be inserted in a given IVF cycle. The United Kingdom limits the transfer of more than two unless the woman is 40 or older. In the United States, however, there are only voluntary guidelines recommended by the American Society for Reproductive Medicine (ASRM), a doctors’ nonprofit group. Those suggest that no more than two embryos should be transferred in women younger than 35. For women between the ages of 35 and 37, like Elizabeth, the limit is three embryos; for women 38 to 40, the limit is four. Yet the Centers for Disease Control and Prevention (CDC) statistics for 2005 (the most recent available) show that only about two dozen clinics in the United States averaged fewer than two embryos. “The guidelines are often not being followed,” says Dr. Thatcher. “It seems that we are unable to police ourselves.”

The IVF process is so complex that we made frequent early morning visits to the clinic. Sometime in the afternoon after one of those same-as-usual appointments, the call came. Elizabeth picked up the phone. After a few seconds, she started to cry. “I don’t believe it!” she exclaimed. According to blood tests, she was indeed pregnant. I stood there in a wordless daze, listening while she asked the nurse whether she had to stop drinking coffee immediately.

The first few weeks were a time of indescribable joy, however tinged with tentativeness and fretting. We were having twins, and had to face the possible complications involved. Still, we felt we made the right decision—and most conservative doctors agree that it is ethical to transfer two or three embryos in women older than 35.

Other doctors say transferring three or more embryos violates the first-do-no-harm rule of medicine, and they suggest it’s happening more often than experts like. One obstetrician said he knows a physician who transferred “seven embryos to a woman, after I heard him say transferring so many was the most outrageous thing of all time.” Like many doctors in his field, he was reluctant to speak on the record because some of his patients come from fertility clinics, and also because his first child was conceived in vitro. “I’ve been on the receiving end of the ‘miracles,’” he says.

Miracles indeed. Worse still, this doctor says, data has shown that transferring more than three embryos at a time may not improve the rate of successful pregnancy, though it does consistently push up the rate of multiples.

These are not new questions for the industry. But it’s troubling that they persist despite improvements in technology. Putting in a handful of embryos and praying that one survives is no longer necessary, Dr. Thatcher says, if it ever was. ASRM has recently begun recommending the transfer of only one embryo in women younger than 35 with a good prognosis. For women between 35 and 37 with a good prognosis, the limit is no more than two embryos; for women 38 to 40, it’s no more than three.

If you really want a baby, though, how objectively can you weigh the risks of transferring more? Many couples are willing to accept the dangers associated with multiples, says Dr. Keefe, and cost is often a motivator. For some, the price tag of IVF virtually requires success on the first or second attempt. Often, says Kari Sproul, M.D., a reproductive endocrinology fellow in Los Angeles, “patients may say, ‘I can’t handle another round of IVF. If you put in three and I get pregnant with triplets, I’ll have a selective reduction.’”

Many clinicians truly want to help their patients achieve their dream of a family, and won’t deny their request if inserting multiple embryos gives them a greater chance. But success rates are also important because they are among the only data that clinics are required to report to the government. The CDC publishes those numbers annually, leading to competition among clinics based on success rates. “The problem is fundamental,” says Dr. Keefe. “Both doctors and patients collude over the issue of the number of embryos to be transferred.”

But patients may not make a level-headed, thoroughly informed decision, sometimes because they don’t get adequate counseling. It’s an oversight that could happen at any clinic, but in a system where every egg is counted, every hormone calculated, some doctors say it’s inexcusable, and it’s another reason more and more doctors believe change is imperative. “The industry should be reformed so that all patients are counseled independently on the long-term risks,” says a top obstetrician in New York City who has delivered hundreds of IVF babies. “And doctors should be far more cautious about transferring more than two embryos, not only because the outcomes can be so difficult, but because society cannot handle the astronomical cost of so many premature babies, including neonatal intensive care.”

It’s not a message that people like to hear. “Everybody loves babies,” says Dr. Keefe. “The typical headline is, great news, so-and-so had quads! But really, it can be a scary, disturbing story. Go to a neonatal ICU to see tiny babies with blindness, bowel problems, lack of lung development. There’s got to be a better way.”

Thankfully, those were complications we never faced. Elizabeth marched through her “high-risk” pregnancy with the same mindfulness and strength that had led us through the IVF process. At every stage we watched the babies growing inside her, and we felt confident by the end that they would be fine. But still, you never know.

One evening last June, we drove up into the Hudson Valley, to a wonderful restaurant where we had no reservation. We knew it would be our last dinner as just the two of us. We were scheduled for a C-section the next day. Twelve hours later my son and then my daughter emerged into the world, bloody and screaming and beautiful. It is impossible to describe my relief and joy when the doctors who examined Edward and Eleanor exclaimed, “They’re perfect!” We had reached the end, and the beginning, that we had dared to hope for.

Our wish for other families

So far, American politicians have spent more hours worrying about human cloning and hindering stem cell research than figuring out how to deal with the moral and medical issues presented by assisted reproductive technology.

Short of strict regulations, which many doctors and patients may find intrusive, there are other ways to encourage better care and safer outcomes. One would be to foster price competition among clinics by posting the costs of procedures, not just success rates. That could drive down prices, enabling couples to afford additional cycles rather than taking greater risks in one cycle. Some doctors believe the government should force more long-term studies of IVF infants, data that is currently lacking, to help fully understand the risks. Others argue that insurance companies could have an impact: “The best thing insurance companies could do would be to say, ‘We’ll cover IVF, but you can only implant one embryo at a time,’” says Dr. Keefe.

For now the most important choices about assisted reproduction rest with clinics and yearning patients. Should any woman accept the transfer of three or more embryos to her womb? Should clinics create high-risk pregnancies that may result in major problems for mothers and infants? I had never considered those issues until we faced them ourselves. But, as Elizabeth often points out, I never could have imagined the two incredibly wonderful children who have transformed our lives, either.

Looking at how healthy and amazing our twins are only affirms my wish that American medicine and government would finally address this powerful technology with realism, compassion and urgency. Our children and families deserve nothing less.

Joe Conason, director of the Nation Institute Investigative Fund and a columnist for The New York Observer and Salon.com, lives with his wife, Elizabeth Wagley, CEO of the Progressive Book Club, and their twins in New York City.